Avoiding Posterior Capsule Rupture

Avoiding posterior capsule (PC) rupture is a major concern with posterior polar cataracts. But the role of anterior segment optical coherence tomography (AS-OCT) in managing it is an open question, as two experts recently debated.

Advantages of preoperative AS-OCT

Absent a ‘fish tail’ sign or a visible PC opening, it is not always possible to determine at the slit lamp whether there is a PC defect, said Namrata Sharma MD. Therefore, preoperative imaging is beneficial.

Although ultrasound biomicroscopy can help, it is a contact procedure limited to examining a single axis. So Dr Sharma recommends swept-source AS-OCT, as it is non-contact and provides 360 degrees of coverage with better resolution.¹

She also noted some advantages of preoperative swept-source AS-OCT over intraoperative OCT: Compared with intraoperative imaging, preoperative imaging has a deeper and wider imaging range, allowing visualisation of the entire lens; it offers magnification and reassessment; and it supports preoperative patient counselling.

“Preoperative imaging with AS-OCT in posterior polar cataracts helps in delineating PC integrity, helps surgeons customise their techniques and tools, and aids in patient counselling in case of change of plans regarding IOL options,” Dr Sharma said. It also provides opportunities to inform patients about the risk of PC rupture and the possible need for vitrectomy, multiple procedures, and prolonged visual recovery.^2,3 However, intraoperative OCT is also useful, especially combined with femtosecond laser-assisted surgery.

Dr Sharma cited several studies demonstrating the accuracy of preoperative AS-OCT. One involving 44 eyes found it identified intraoperative PC dehiscence with 97% sensitivity and 87% specificity as well as 97% positive predictive and 77% negative predictive value for a total diagnostic accuracy of 95.4%.⁴ Another involving 100 eyes found similar accuracy.⁵

An AS-OCT study she and her colleagues published examining posterior polar cataract morphology found that those with a conical or moth-eaten appearance had a 100% PC rupture rate and those with ectatic appearance, 66%.⁶

“I think it’s a great tool to have because which other tool can predict PC rupture that accurately?”

Preoperative imaging is not necessary

Arguing the opposing side, Abhay R Vasavada noted that a good clinical examination and proper surgical technique and tools—potentially including femtosecond lasers—can cut the incidence of PC rupture with posterior polar cataracts to 4–8%, which he said renders preoperative imaging superfluous.

Many posterior opacities seen in the real world are actually localised plaque cataracts, but are mistaken for posterior polar cataracts, Dr Vasavada noted. “You need to look on the slit lamp—you don’t need any other thing.” He advised looking around the posterior polar area for a ‘punched out’ area, which often indicates a capsular defect.

A sinking cortex is another sign that a capsular defect is present, Dr Vasavada said.⁷ The ‘fish tail’ sign is yet another. “It is very obvious; it doesn’t need any imaging.”

Identifying fragile capsules is important because they can rupture at any point in the surgery, Dr Vasavada noted. Any manipulation near a posterior polar cataract can cause a rupture because it is not only fragile, but very adherent.

Once identified, imaging does not help manage a fragile capsule, Dr Vasavada emphasised, but proper surgical technique does. Crediting Dr Robert Osher, he outlined a standardised technique for avoiding rupturing fragile capsules. Principles include:

·                Avoid rapid build-up of hydraulic pressure.

·                Create a mechanical cushion effect.

·                Avoid forward bulge of the capsule-zonule diaphragm.

·                Create a communication between anterior and posterior compartments.

·                Use femtodelineation.

·                Counsel the patient and family.

Dr Vasavada noted that using conventional hydrodelineation resulted in a 36% capsular rupture rate in his clinic.⁸ Switching to inside-out delineation lowered the rate to 8%, which dropped further to 3.8% with femtodelineation.^9,10 His current rates are similar, he said.

“If you can reduce [PC rupture] to about 4%, is it really necessary to use intraoperative OCT? Preoperatively, I think all the detailed examination is a good thing, but generally it is not necessary,” Dr Vasavada said, adding imaging does not replace the need for proper surgical technique.

Yet ruptures still occur, so he advises being ready to manage them through the very end of the case. “Posterior polar cataract is not over until it is over,” Dr Vasavada said. “So, if your nurses and assistants start packing up [before you are finished], don’t let them do it.”

Drs Sharma and Vasavada debated this topic during the JCRS Symposium at the 2025 ASCRS annual meeting in Los Angeles.

Namrata Sharma MD, FRCOphth, FRCS(Ed) is professor of ophthalmology at the All India Institute of Medical Sciences, New Delhi, India. namrata.sharma@gmail.com

Abhay R Vasavada MS, FRCS(Eng) is founder and director at Raghudeep Eye Hospital, Ahmedabad and Jaipur, India. icirc@abhayvasavada.com

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8. J Cataract Refract Surg, 1999; 25: 238–235.

9. Vasavada AT, Raj SM. J Cataract Refract Surg, 2004; 30: 1167–1169.

10. Vasavada AR, et al. J Cataract Refract Surg, 2015; 41: 702–707.